- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.35 / $1,061.69 / $1,061.69
| Professional | | $560.35 | $1,061.69 | $1,061.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.26 / $972.84 / $1,423.04
| Professional | | $765.26 | $972.84 | $1,423.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.45 / $1,061.69 / $1,541.00
| Professional | | $652.45 | $1,061.69 | $1,541.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.29 / $928.69 / $1,445.04
| Professional | | $834.29 | $928.69 | $1,445.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.35 / $1,061.69 / $1,061.69
| Professional | | $560.35 | $1,061.69 | $1,061.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.66 / $843.41 / $1,178.22
| Professional | | $581.66 | $843.41 | $1,178.22 |